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Home My WebLink AboutBLDP&G-17-000936 - \ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK j =wP_E4 ,�� a..114=7 y CITY L ,^ r,,"Ji1 cJ /-1 IQ MA DATE{ 9 i 1 PERMIT, . -/7 4�# / ft �� JOBSITE ADDRESS -// ///(1/n`)j/`l�JCaC '� J OWNER'S NAME %C Ai ?n/")_ 1) OWNER ADDRESS V l/'Vfr l✓72-/ TEL 5 DY‘,9, /t7/1FAXJ 1 TYPE OR OCCUPANCY TYPE COMMERCIAL® EDUCATIONAL D RESIDENTIAL 1 !v\ PRINT CLEARLY NEW:E1 RENOVATION:LI REPLACEMENT:E} PLANS SUBMITTED: YES LI NO NFIXTURES 1. FLOOR---* BSM •1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB iF I ____ :7_7—'.1-7_ T'r.,. .II .. ._il _.Lr `F-7- .._ JI`.ih_. ,( CROSS CONNECTION DEVICE i._ . .I_ >^ r _Il ME F-71_ .__`:I .. _ I : DEDICATED SPECIAL WASTE SYSTEM [ I .- . .i(. . . I^-`r� $r7 +I__ I __ L II._ i 1.__ :(�7; I J DEDICATED GAS/OIUSAND SYSTEM l__ 1.. : T;I -IY_A91 ?[,, . T- 7 r .,I.. -' ?r.__[. DEDICATED GREASE SYSTEM [.___ [ � :I. 1 L___„;l_,,, ih it 11 _id__ C�r1 _.._fir 7r-- DEDICATED GRAY WATER SYSTEM 1.._1-.. ;[--7r [. .. ;1�,r i �lr�?r-- rT 1[ '.I lr--fir DEDICATED WPTER RECYCLE SYSTEM i� (—�[ i 11 ir— 4 z(_._ 1 31_. T7 `I— .-3I- 77 DISHWASHER I:, I. I :.�f I II..... 1. -- 1 .'r [_ 'I `i(._ . . I _. L:_ DRINKING FOUVTAIN r .��:1 11, Imo,�VI� 'fit- 3�_ Ir M1I r-,r_ii-1. ''E_:-j FOOD DISPOSER 1,= - I E I-_ 1I [ - r" . I '1 �-r'1E 1 ,.:. �,� FLOOR/AREA DRAIN 1 �r, 1,-� 1 s.,- 1��I_ jl. a ., _ 1 ."r 'r ,r��. {—___r — INTERCEPTOR(INTERIOR) I --II__. ..1r.�r- � 'r 1��- 1 .-1. 'I...,. i _1---r �` ` i - 1- ;I 1 _._n r 1i '.�-(I 1 -T t - I. . 'r - . I KITCHEN SINK _ _ ._„ LAVATORY I--_' :1 I_:_ 1 I�. (-73 I_, . .i 1—(- :I� I -1 . _1� rV _;r -. ROOF DRAIN 1.,,-� it ;I—'r—I771{77.11._ _ 1 ._ 1 . •`r-----.r-- 1 i. - . -[ SHOWER STALL --.,�,�.11_-.11- , ll.....-ih2_a,:_ .,II___ _I�-(—lr-'.r-1 __.i 1 .r J SERVICE I MOP SINK —1r= _ L__ EI. — TOILET I_._,._1I_<T-r_. 1 .. .'1 I__ �il__._ _.�1, —,.q 1: -_ t1 ',1 ,:r---.1.... •r URINAL 1.__Ir. __ram it _ I -.:1i r.. .. 1--:� . 'r , _, I ry WASHING MACHINE CONNECTION I • 91_ Fr—.1r-- ._'1I_ -- II .1r ' -`1 . 1~-1I�� -1 1 ' WATER HEAT=R ALL TYPES 1—..--.!t ., �- Lr _,I `'--'[ . IF._,.,_t1- - iI—'r- .. L__ , -f __'l WATERPIPINS _ ,r-1 -77---_Ir- . :I.zd_,I i `r '1- ' it .. .1 _a OTHER _ 1r-_ .i1- .- :- 1__ i 71 -'r ••I .__I.. .I�r-; 'I [^ I_ ► 41 F.. . I •a 11—f-1 -. 1 1 f— , f---- INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES 0 NO F. IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 2 OTHER TYPE OF INDEMNITY 0 BOND Li OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the 1 Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER 0 AGENT L SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and Installations performed under the permit Issued for this application will be in corn (lance with all Perti ent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME I STEPHEN A.WINSLOW LICENSE# 12298 [- • SIGNATURE MPIJ Pp CORPORATION# 3281C PARTNERSHIPIC_ LLCD#. COMPANY NAME EF WINSLOW PLUMBING&HEA� TING ADDRESS LIKARDON CIRCLE — CITY SOUTH YARMOUTH ii STATE ap7=3 ZIP 02664 _ - _ TEL 508-394-7778 —_, ____�_ FAX 508.394-8256 CELL I N/A 1 EMAIL accounts ayable@efwinslow,com _ �� a' 4 Department of Industrial Pdcctaents KM.. t Office of Investigations ., f. 'In= ' 600 Washington Street =`��- � Boston,MA 02111 • www.mass.gov/ilia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information 1 , Please Print Legibly Name(Business/Organization/Individual):l.' •WIrkS{Cr evl �(V0...tdiekcj 2A<QVI c .)lei(. Address: ' (4crawl C ira.e- City/State/Zip: Soskh WYvs^cm.-k+ MPr Phone#: '50b-3c14i1'17S Are you an employer?Check the appropriate box: Type of project(required): ,,{1I am a employer with '70 4. 0 I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors :.❑I am a sole proprietor or partner- listed on the attached sheet.t 7. ❑Remodeling ship and have no employees These sub-contractors have 8. 0 Demolition working for me in any capacity. workers'comp.insurance. 9. 0 Building addition [No workers'comp.insurance 5. 0 We are a corporation and its 10.0 Electrical repairs or additions required.] officers have exercised their i.❑I am.a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions . myself.[No workers'comp. c.152,§1(4),and we have no 12.0 Roof repairs insurance required.]t employees.[No workers' 13.❑Other comp.insurance required.] lay applicant the checks box#1 must also fill out the section below showing their workers'compensation policy information. Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. :}ontractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. km an employer that is providing workers'compensation insurance for my employees.Below is the policy and job site 1 formation. - tsurance Company Name: PPCI 0•..j r‘v o.A d -i c.wc&e1 C-2 cuuntkivi olicy#or Self-ins.Lic.#: \S o.I A. • Expiration Date: (-1- aol") it,Site Address:,D3 Corw,Acynwee-Ai'h 1 iQy CG\3t0lYi' l t\ City/State/Zip: O 4to7 ttach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). ailure to secure coverage as required under Section 25A of MGL c.152 can lead to the imposition of criminal penalties of a ne up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine Fup to$250.00 a da a ainst the violator. Be advised t at a copy of this statement maybe forwarded to the Office of • tvestigations the DIA for insurar�e=ryoverage veri on. / do hereby certify un a ains an l(penalties of pe jury that the information provided above is true and correct. ianati?e: Date: (a)3 1 I ao lb' hone#: .SLID .314-'777g Official use only.Do not write In this area,to be completed by city.or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK - -_G1 CITY V r 'I' Jr % _ : MA DATE i 1 PERMIT# t t "/7— % JOBS1TE ADDRESS+ V i � 1 Ui J iM / 11 OWNER'S NAME fic «1`i1✓1rf} G Jr Al ____., OWNER ADDRESS ' -4...Lt. 7 , f-- TEL . . Q/) , I q/ lFAXL 1 TYPE OR(\rr\ OCCUPANCY TYPE COMMERCIAL -:„T EDUCATIONAL Ci RESIDENTIAL D CLEARLY NEW:Eli RENOVATION: D REPLACEMENT: piPLANS SUBMITTED: YES El No „RA j APPLIANCES •1 FLOORS-3 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER I .:_.7 I _ . i _! - _ +. H7.7 _. .._t a _'I.._ i l _.,1 i.. 71j.. ..'_._i y. BOOSTER r I_ I 1.... ._ . 'I. 'I _.i... ..._` 'I. w. 11—_ . ,l__ . Yi. .. I _ _;!._. s I(. :.....�!. �o-r ET -_s...._va ___.Jr1 v�r �T_r<... .t�u..a._. y..s� .!R-`- CONVERSION BURNER -. - i E. 1__ Il_._.. ..tl `'I_ . i - COOK STOVE 1 • + 1. . i 1 _ r r.17� ' _"_ `I 11� _ _ i 1 . i h �_i i _ 111. I . ,� DIRECT VENT HEATER 1K._ . -i 1--------i I..yy.'i_ 1---- _.. I.r_7..:,-.. +,I.--- . 1 h. _::�:' 1 �:._ - -- F.�. 7•�' I... � ,_ I I. I.I._ .t�. !_ . DRYER ITT'• �. . Ci— .--1 E.7. .. —' _� .w - __. 3-- _ �,��, .: ,... ,- FIREPLACE - �__ L I. " _A. ,1 +�� .7.......-�' ,:._� 'l�• l .::w i. 1! _ �L. FRYOLATOR I_. . 1 Is I J . if'. aY __._.4!. 1 _ y ! ' 1. ,I _. i I t l FURNACE 1 _{ Iij`-` I ;I - �. - _ i T i_ : ; L;! `;f `I - �(I f{ GENERATOR j 1_ ...:. i-..-_ .. . •1 .�..-s _..... .'- _.1. ..._: _;N_---.'1-:.-... . I I ..1..._. . - ._..'I . .. GRILLE c::i 11. Y 1 _ _.. :.� t ' �_ ...� i• INFRARED HEATER I- _. .� �._. ! -- - ' _._ ' • LABORATORY COCKS I . I._ 'I._ . . I_ - .'. i iI- ___ _ I� _ .1 . . I. . I i. I ;.. _,...2. z_�.� ;II -- t MAKEUP AIR UNIT I- i E___ I-~_'.I_ . .` �,_-_. :1 .. ._I . _.�1 _ - - -_ 'I--_4- 1 :1I 1!._� . _1I-1I ,.I (' �(i. _) _. . ,1 ....1 . :I --- -_`1 �u. 1I 1 °iy _ OVEN __ . - .. _ �- _ - _ - i' l; lam` ' _ • KI ' .._ . �f ._ 1I .I l�`FI . Il.. �,• 1 POOL HEATER I 1 11 . . , I _IL.. . . _ . ,., L. . SPACE HEATER ��^►I . __f 1_. .._ 1- I '1 1i -(1 1�� 1- -,�.17- ROOM ! ._ _ _ L ._ ,! ROOF TOP UNIT i,.__ _ I E- . it-� ,11 . .. L 1- -___1i . . il. _f 1= . t I_ = Vl i '1• _. t f I� _._. .. tI 1 •1 17 i� '1 ._ ' .-.. . v1 _.__ i,. .�. :__: -�I : _.) ._. _,E1_ i• TEST - _ _- c-. N 1_ UNIT HEATER 1. . . � l.. . . ..I � '1 :.L _-... . _ I. . I . _ I � � .UNVENTED ROOM E EATER �i I. I .. ._' LTTiEE13� I•. . I "r 2 -..1 Of E I �1 + ': .I-- - :I. SI I ,1 :i i i• i. WATER HEATER . . . _ . • . _ - . OTHER I ._11_ -- - ' (_ . . .t ''�._ _ .___ -- .. _ 11_ ,�-I ►:I- .d i ...,,�,R,,,.......,_...�....,,.,...�,...a.r...�.u.��..�... . 11 41 tOC7WT_• •sl-, � O _ r ILL "JZ—' F LT • ' i ,Zi•i,, _ ( l rC m. :. Lt .., , INSURANCE COVERAGE I have a current liability insurance policy •or its substantial equivalent which meets the requirements of MGL, Ch. 142 YES NO �„i I 1F YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY El OTHER TYPE INDEMNITY El BOND L,1 OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER 'r AGENT D' SIGNATURE OF OWNER OR AGENT hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit Issued for this application will be in compllanbe with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. C.._'1 /// --'1-- Z.A.-49 i . 722-4-te--Zi'zit- STEPHEN A. WINSLOW 1LICENSE #.12298 I - / SIGNATURE PLUMBER-GASFITTER NAME „ LPGI CORPORATION ' 81C frARTNERSHIP #L ,. .. ., _.. � LLC�# . J MP ,� MGF JP � JGF I,m,# 32 COMPANY NAME: ETWINSLOW PLUMBING & HEATiN i ADDRESS-8 REARDON CIRCLE _ '� STATE � � _ ., SOUTH CITY YARMOUTH MAI ZIP 02664 iTEL 508-394-7778- - _ — FAX 508-394-8256 —' CELL -1--( EMAILlEca.11itsza yable@efwinslow.com 4—N.mi— Office of Investigations : — i- 600 Washington Street Boston,MA 02111 .-t., .tYu0 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information ` ' n Please Print Legibly Name(Business/Organization/Individual): E,e•W 1 It t OW ` (��to t�nc'i a. c {.a\'. � Qt., l eI C . U Address: ' (4odcv, C:uti-'.- . City/State/Zip: Soo�h )(or'v"cs.r M}c Phone#: S- YV1 1')7 I Are you an employer?Check the appropriate box: Type of project(required): AI am a employer with -70 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors ;.❑ I am a sole proprietor or partner- listed on the attached sheet.t 7 ❑Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me any capacity. workers' comp.insurance. 9. [I Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions • required.] officers have exercised their 1.❑ I am.a.homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions . myself.[No workers' comp. c. 152,§1(4),and we have no 12.0 Roof repairs insurance required.]t employees. [No workers' 13.0 Other comp.insurance required.] .ny applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. :ontractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site formation. isurance Company Name: .as M01' aA _,L41,f UfCA.6(Q CeU�,/'t/1'-.-j olicy#or Self-ins.Lic.#: ‘ (is I A . Expiration Date: k—t - au-) A)Site Address: 3 GC3rvv+Aan 'c--i` y e :S1\ I .1 41 City/State/Zip: O,)"-i 10 7 .ttach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). allure to secure coverage as required under Section 25A of MGL c.152 can lead to the imposition of criminal penalties of a • ne up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine f up to$250.00 a da against the violator. Be advised t at a copy of this statement may be forwarded to the Office of • ivestigations the DIA for insurape overage veri ion. do hereby certify un e ns an penalties o pe jury that the information provided above is true and correct. ignatttre: r Date: (Di 3 t l RO( hone#: .5"lYk-354-- ?77D' Official use only. Do not write in this area,to be completed by city or town official - City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: